Today's health care industry is structured so that, in most cases, service providers (e.g., doctors, hospitals, other medical professionals) receive reimbursements from medical plans (e.g., private insurance plans or government-sponsored medical plans). Under these approaches, the medical plan typically determines how much to reimburse a provider for a particular procedure or service. The health plan may also determine if it even will reimburse a provider for a service and, if the service is reoccurring, how often to reimburse the provider for the service.
Quality of service concerns have been raised by many with respect to today's health care environment. Unfortunately, available methods of reimbursement have provided little financial reward for improvements in the quality of healthcare delivery. For instance, fee-for-service payments encouraged overuse while capped payments encouraged underuse, and neither approach rewarded providers based on quality. Pay-for-Performance (P4P) initiatives have been implemented in the health care industry with the intent of addressing rising healthcare costs and improving quality.
In many previous P4P approaches, the amount of reimbursement was determined by a provider performance assessment (e.g., a score). For instance, the health plan tracked the records of patients (enrolled in the health plan) and whether the provider had provided (or offered to provide) certain services for patients having a particular condition. The more patients of the provider that met the standard, the higher the score for the provider. Moreover, the higher the score, the higher the reimbursement for a provider offered by the health plan.
In some previous systems, medical chart data was sometimes used for reimbursement purposes. While medical chart data was considered an accurate source of information regarding the care provided by physicians, data collection on a wide scale for the purposes of provider performance assessment was not cost effective and placed a significant burden on providers from an administrative perspective. Hence, health plans focused on the use of administrative claims (and the data included with these claims) submitted by the provider to determine performance assessment measurements.
However, problems have arisen regarding the accuracy of using administrative claims data alone for provider performance assessment measurements. For instance, the health plan may be mistaken that a particular procedure was not performed on a patient, thus incorrectly lowering the score. In another example, a valid reason (e.g., an exclusion) may exist for not providing a service for a patient, again resulting in the incorrect lowering of the provider score. Previous approaches have not addressed these concerns.
Additionally, as P4P programs have continued to mature, providers in turn have grown in their understanding of measures, scoring practices and other program design issues. Previous systems have not been structured to provide transparency for the provider in terms of the how their assessment is calculated.
The technology used to implement previous systems has also proved problematic. For instance, in systems that use paper communications, the provider typically filed a paper request for reimbursement, this paper request was received and analyzed by the health plan, a reimbursement decision was made, and the reimbursement decision (with any reimbursement) was communicated to the provider. Unfortunately, this type of system was slow and prone to errors.
Although computer-based systems have more recently allowed data to be more quickly communicated and analyzed, these systems often required that the provider purchase custom software in order to participate and required significant time to learn. These limitations resulted in inconvenience and extra cost for the service provider.
Because of the above-mentioned problems, the frustration level of service providers has increased and the quality of service offered by the health care industry has decreased. As a result, health plans are finding it increasingly more difficult to increase or maintain provider participation and increase their quality of service.
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